Selection of PIP Medical Coverage - Michigan

AGENCY:

MICHIGAN SELECTION OF PERSONAL INJURY PROTECTION (PIP)

MEDICAL COVERAGE ? INDIVIDUAL(S)

APPLICANT/NAMED INSURED:

INSURANCE COMPANY:

POLICY/QUOTE NO.:

EFFECTIVE DATE:

READ THIS ENTIRE FORM CAREFULLY

THE PURPOSE OF THIS FORM The purpose of this form is to explain the choice you have regarding your Personal Injury Protection (PIP) medical coverage and to assist you in making that choice. Read this form carefully because the choice you make will have financial consequences.

Personal Injury Protection (PIP) Medical Coverage Explained

Personal Injury Protection (PIP) pays allowable expenses for your care, recovery, rehabilitation, wage loss and replacement services. PIP coverage also includes some funeral expense benefits and survivor's benefits which are paid to your dependents if injuries from an auto accident result in your death. This form allows you to select the level of PIP medical coverage you want included with your auto policy. This form is divided into three sections, which are described below.

? Section A will review your PIP medical coverage options and the risks and benefits of each option. ? Section B will ask you to choose ONE coverage option. ? Section C will ask you to certify your choice and acknowledge the information within this form.

NOTICE You must choose the level of PIP medical coverage you wish to have under your auto policy. If you do not make a selection from the options listed:

? Your policy will be issued with unlimited PIP medical coverage; AND ? You will be charged the appropriate premium for this coverage.

Definitions

The terms in bold letters throughout this form are defined below for informational purposes only and are not intended to limit or expand coverage that may be available in a particular policy.

Applicant means a person who has submitted an application for insurance but is not yet insured under a policy.

Attendant care means services to assist an injured person with tasks they would normally do for themselves (e.g., eating, bathing, dressing, grooming, and medication administration). It may also involve supervision or other types of support.

Excess attendant care means additional coverage purchased for attendant care above the PIP medical coverage limit selected for your policy.

Michigan Assigned Claims Plan is a program that may pay benefits to people injured in an accident involving a motor

vehicle when there is no applicable auto insurance policy.

Named insured means the individual(s) named in an insurance policy.

Personal Injury Protection (PIP) Medical is coverage under an auto insurance policy issued in Michigan that pays allowable expenses for medical care, recovery, rehabilitation, and some funeral expenses.

Qualified health coverage means either of the following: ? Health and accident coverage that does not exclude or limit coverage for injuries related to auto accidents and has an annual individual deductible of $6,000 or less; OR ? Coverage under both Medicare Parts A and B.

Medicaid and health care sharing ministries are examples of coverages that are NOT considered qualified health coverage.

Resident relative means a relative of either you or your spouse who lives in the same household.

Ed. 7/2/2020

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Section A: Your PIP Medical Choices and the Risks and Benefits of Each

Option 1: Unlimited Coverage

This option provides the most coverage. It will pay for all allowable expenses for your care, recovery, and rehabilitation if you are injured in an auto accident.

Risks

The premiums for this option are higher than premiums for other options.

Benefits

PIP medical will cover costs that may not be covered by health insurance, such as rehabilitation and attendant care.

This choice will significantly limit the risk that you will have out-of-pocket costs for your care.

Option 2: Limited Coverage of $500,000 or

Option 3: Limited Coverage of $250,000

If you choose one of these limits, this amount is the most your auto insurance company will pay per person per accident for an injured person's expenses under PIP medical coverage.

Risks

Limited PIP medical coverages may not be enough to cover your medical expenses. If your PIP medical limit is reached, you may need to rely on other health coverage, which may not cover all medical, rehabilitation or attendant care costs. If you do not have other health coverage, you may be personally responsible for paying these expenses.

NOTE: Your insurance company must offer excess attendant care coverage, which you may purchase for an additional premium. Check with your agent or company for additional information.

Benefits

Lower coverage limits have less expensive premiums than plans with higher or unlimited PIP medical coverage.

Up to the limit chosen, PIP medical will cover the cost of products and services that may not be covered by health insurance, such as rehabilitation and attendant care.

Option 4: Limited Coverage of $250,000, with some or all persons excluded from PIP medical

This option is only available if you choose the $250,000 PIP medical limit.

? A named insured who wishes to exclude PIP medical must have qualified health coverage that is not Medicare.

? Any resident relative or spouse who wishes to exclude PIP medical must have qualified health coverage.

Anyone who is excluded will have no PIP medical coverage. Anyone who is not excluded will have $250,000 in PIP medical coverage.

Risks

ANYONE YOU EXCLUDE WILL NOT HAVE PIP MEDICAL COVERAGE.

In addition:

? Persons relying on qualified health coverage to pay for auto accident injuries should be

aware that, unlike auto insurance, health insurance stops paying when the policy ends or is canceled.

? If any excluded person loses qualified health coverage, you must notify your insurer within

30 days of loss of coverage. ? Within 30 days of losing qualified health coverage, if an excluded person is injured in an

auto accident, coverage will be provided by the Michigan Assigned Claims Plan up to $250,000 if they have no other qualified health coverage or PIP medical coverage. ? A person who has not obtained qualified health coverage or PIP medical coverage within 30 days of the loss of coverage will not be entitled to any PIP medical benefits.

NOTE: Your insurance company must offer excess attendant care, which you may purchase for an additional premium. This coverage is only available to those who are not excluded from PIP medical coverage. Check with your agent or company for additional information.

Benefits

You will pay a reduced premium because you will not be charged a premium for PIP medical coverage for anyone who is excluded.

Ed. 7/2/2020

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Section A (Continued)

Option 5: Limited Coverage of $50,000

If you choose this limit, $50,000 is the most your auto insurance company will pay per person per accident for an injured person's expenses under PIP medical coverage.

You may select this option if:

? The applicant or named insured is enrolled in Medicaid; AND ? Any spouse and all resident relatives have one of the following:

a) qualified health coverage; b) Medicaid enrollment, or c) coverage under another auto policy with PIP medical coverage.

Risks

Limited PIP medical coverages may not be enough to cover the cost of your medical care. If your PIP medical limit is reached, you may need to rely on other health coverage, which may not cover all medical, rehabilitation, or attendant care costs. If you do not have other health coverage, you may be personally responsible for paying these expenses.

NOTE: Your insurance company must offer excess attendant care coverage, which you may purchase for an additional premium. Check with your agent or company for additional information.

Benefits

Lower coverage limits have less expensive premiums than plans with higher or unlimited PIP medical coverage.

Up to the limit chosen, PIP medical will cover the cost of products and services that may not be covered by health insurance, such as rehabilitation and attendant care.

Option 6: No PIP medical coverage for anyone covered by this policy

You may select this option if:

? The applicant or named insured has coverage under both Medicare Parts A and B, AND ? Any spouse and all resident relatives covered by the policy have qualified health coverage or are covered

under another auto policy with PIP medical coverage.

Risks

NO PIP MEDICAL COVERAGE WILL BE PROVIDED UNDER YOUR POLICY.

You and any other persons covered by this policy will not have PIP medical coverage. You and those persons may have to rely on other health coverage to pay for medical expenses resulting from an auto accident, which may not cover all products and services that PIP medical provides.

? Persons relying on qualified health coverage to pay for auto accident injuries should be aware that, unlike auto insurance, health insurance stops paying when the policy ends or is canceled.

? If anyone covered by the policy loses qualified health coverage, you must notify your insurer within 30 days of loss of the coverage.

? Within the 30 days of losing qualified health coverage, if anyone covered by the policy is injured in an auto accident, coverage will be provided by the Michigan Assigned Claims Plan if they have no other qualified health coverage or PIP medical coverage.

? A person who has not obtained qualified health coverage or PIP medical coverage within 30 days of the loss of coverage will not be entitled to any PIP medical benefits.

Benefits

You will pay a reduced premium because your policy will not be charged a premium for PIP medical coverage.

Ed. 7/2/2020

Page 3 of 4

Section B: PIP Medical Coverage Options and Certification

Make your selection carefully because the choice you make will have financial consequences. If you choose more than one option, your insurer will provide you with the option that has the highest level of benefits and will charge the appropriate premium for that option.

INITIAL ONE AND ONLY ONE option on the line next to your choice.

______ Option 1: Unlimited coverage OR

(Initial)

______ Option 2: $500,000 per person per accident OR

(Initial)

______ Option 3: $250,000 per person per accident OR

(Initial)

______ Option 4: $250,000 per person per accident with exclusions OR (Initial) By selecting Option 4, you certify that one or both of the following are true:

? A named insured who is excluding PIP medical has qualified health coverage that is not Medicare. ? Any resident relative or spouse who is excluding PIP medical has qualified health coverage.

Full Name of Each Excluded Person on the Policy

Date of Birth

______ Option 5: $50,000 per person per accident OR (Initial) By selecting Option 5, you certify that both of the following are true:

? The applicant or named insured is enrolled in Medicaid; AND ? Any spouse and all resident relatives have qualified health coverage, is enrolled in Medicaid, or are

covered under another auto policy with PIP medical coverage.

______ Option 6: No PIP medical coverage. (Initial) By selecting Option 6, you certify that both of the following are true:

? The applicant or named insured has coverage under both Medicare Parts A and B; AND ? Any spouse and all resident relatives have qualified health coverage or are covered under another

auto policy with PIP medical coverage.

Section C: Certification

You must initial each line and sign and date this form.

______ I have read this form. I understand the PIP medical options available to me and the benefits and risks associated (Initial) with those options.

______ I have made a coverage selection and I understand that the selection I have made applies to me and any other (Initial) person claiming benefits under this policy.

______ I understand that if I have not made a selection my policy will be issued with unlimited PIP medical coverage (Initial) and I will be charged the premium for this option.

______ I understand that if I have chosen Option 4 or Option 6, I must notify my insurer within 30 days if a person who (Initial) has qualified health coverage loses their qualified health coverage. A person who has not obtained qualified

health coverage or PIP medical coverage within 30 days of the loss of coverage will not be entitled to any PIP medical benefits.

APPLICANT/NAMED INSURED SIGNATURE

DATE

Ed. 7/2/2020

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